What is the surgical risk for a patient with a history of Chronic Diastolic Congestive Heart Failure (CHF), Hypertension (HTN), and Hyperlipidemia (HLD) undergoing Ptosis Repair with normal Left Ventricular Ejection Fraction (LVEF) and mild to moderate aortic regurgitation (AR)?

Perioperative Risk Assessment for Ptosis Repair in a Patient with Diastolic CHF, HTN, and HLD

This patient undergoing ptosis repair is at low surgical risk based on preserved cardiac function, normal stress test, and the low-risk nature of the ophthalmologic procedure.

Risk Assessment Analysis

Cardiac Status Evaluation

• Patient has diastolic CHF with preserved ejection fraction (60-65%)
• Normal stress test (Lexiscan) showing no significant fixed or reversible perfusion defect
• No significant scar or ischemia
• Mild to moderate aortic regurgitation (AR)
• Comorbidities include HTN and HLD

Procedure Risk Stratification

• Ptosis repair is classified as a low-risk ophthalmologic procedure 1
• Ophthalmologic procedures are specifically mentioned as "lowest risk and rarely associated with excess morbidity and mortality" 1

Risk Factors Analysis

1. Heart Failure Status:

   • Diastolic heart failure with preserved EF (HFpEF)
   • Current LVEF is normal at 60-65% 1
   • No symptoms of decompensated heart failure mentioned

2. Valvular Heart Disease:

   • Mild to moderate AR
   • In asymptomatic patients with moderate AR and normal LV function, it is reasonable to proceed with elective noncardiac surgery (Class 2a recommendation) 1

Evidence-Based Risk Assessment

The 2024 AHA/ACC perioperative guidelines indicate that heart failure is an established risk factor for poor outcomes after noncardiac surgery 1. However, several factors mitigate this patient's risk:

1. Preserved Ejection Fraction: The patient has normal LVEF (60-65%), which significantly reduces perioperative risk compared to patients with reduced LVEF 1

2. Stable Heart Failure: No mention of active HF symptoms or signs of decompensation

3. Negative Stress Test: Lexiscan showed no significant ischemia, which is reassuring 1

4. Low-Risk Procedure: Ophthalmologic procedures like ptosis repair are classified as low-risk surgeries 1

5. Mild-Moderate AR: The 2021 ACC/AHA guidelines state: "In asymptomatic patients with moderate or greater degrees of AR and normal LV systolic function, it is reasonable to perform elective noncardiac surgery" 1

Management Considerations

Despite the overall low risk, certain precautions should be taken:

1. Hemodynamic Management:

   • Avoid tachycardia and hypotension which can worsen diastolic dysfunction 2
   • Maintain euvolemia to prevent both pulmonary congestion and inadequate preload

2. Medication Management:

   • Continue antihypertensive medications through the perioperative period
   • ACE inhibitors and beta-blockers have been associated with improved survival in patients with diastolic heart failure 3

Potential Pitfalls and Caveats

1. Fluid Management: Patients with diastolic dysfunction are sensitive to volume status changes. Too much fluid can precipitate pulmonary edema, while too little can reduce cardiac output 2

2. Blood Pressure Control: Maintaining appropriate blood pressure is critical as both hypotension and hypertension can be problematic in diastolic heart failure

3. Monitoring: While invasive monitoring is not routinely needed for low-risk procedures, careful attention to vital signs is important

Conclusion

Based on the 2024 AHA/ACC perioperative guidelines and other evidence, this patient has multiple favorable factors: preserved LVEF, negative stress test, stable cardiac status, and a low-risk ophthalmologic procedure. The mild to moderate AR with normal LV function does not significantly increase perioperative risk according to current guidelines 1.